Nanda Nursing Diagnosis

Hepatic cirrhosis is a chronic disease of the liver with inflammation and liver fibrosis which results in the distribution of hepatic structures and loss of most liver function. Major changes that occur due to cirrhosis are the death of liver cells, the formation of fibrotic cells (mast cells), cell regeneration and scar tissue that replaces normal cells (Baradero, 2008).According to Black (2014) liver cirrhosis is a progressive chronic disease characterized by extensive fibrosis (scar tissue) and nodule formation. Cirrhosis occurs when the normal flow of blood, bile and hepatic metabolism is altered by fibrosis and changes in hepatocytes, bile ducts, vascular pathways and reticular cells. Cirrhosis is the final stage in many types of liver injury. Cirrhosis of the liver usually has a nodular consistency, with bundles of fibrosis (scar tissue) and small areas of tissue regeneration. There is extensive damage to hepatocytes. Changes in heart shape change the flow of the vascular and lym...

Hydrocephalus is a buildup of fluid inside the skull, leading to brain swelling. Hydrocephalus is caused by cerebrospinal fluid flow problems, the fluid that surrounds the brain and spinal cord. This fluid carries nutrients to the brain, eliminating waste from the brain, and acts as a cushion. CSF normally moves through the area of the brain called ventricles, around the outside of the brain and spinal cord. This fluid is then absorbed into the bloodstream. Fluid buildup can occur in the brain if the flow or absorption is blocked or if too much fluid is produced. Accumulation of fluid puts pressure on the brain, pushing the brain to the skull and damaging or destroying brain tissue. Hydrocephalus - Nursing Diagnosis and Interventions (NIC - NOC) 1. Ineffective cerebral tissue perfusion related to the increased volume of cerebrospinal fluid. NOC: Circulation status Expected outcomes (NOC): 1. Shows the status of circulation which is characterized by the following indicators: Systolic a...

Nursing Care Plan for Dermatitis Dermatitis is inflammation of the skin. Dermatitis can have many causes and occurs in many forms. Dermatitis usually involves an itchy rash on swollen, reddened skin. Dermatitis is a common condition that's not contagious and usually isn't life-threatening. Even so, it can make you feel uncomfortable and self-conscious. Disturbed Body Image related to the appearance of the skin that is not good. Goal: Development of an increase in self-acceptance. Expected outcomes: Develop an increase in the willingness to accept a state of self. Follow and participate in self-care measures. Reported feeling in control of the situation. Reinforces the positive support of the self-governing. Express attention to self-healthier. Seemed not to notice the condition. Using a technique to hide flaws and emphasize techniques for improving the appearance. Interventions : 1. Assess the patient's self-image disturbance in (avoiding eye contact, self-deprecating speec...

Trachoma is the world's leading cause of preventable blindness and the second cause of blindness after cataract. Blindness from trachoma occurs after years of repeated infection with the microorganism, Chlamydia trachomatis. The process of infection and re-infection starts in early childhood and may continue to adulthood, if the cycle is not broken. Women have a two to three times the rate of advanced trachoma and blindness than men, because as mothers, grandmothers and older sisters who care for children (the main source of active trachoma infection), they are redundant and are constantly exposed to bacteria. Trachoma is caused by Chlamydia trachomatis and is spread through direct contact with the eyes, nose, and throat are exposed to liquid (containing bacteria) of people living with, or in contact with inanimate objects, such as towels and / or rags, which once contact is similar to the liquid , Flies can also be a route of transmission. If left untreated, repeated trachoma infe...

Nursing Care Plan for Congenital Heart Disease Congenital Heart Disease (CHD) is a heart disease which is inborn, because it occurs when a baby still in the womb. At the end of the seventh week of pregnancy, heart formation is complete; so the formation of cardiac abnormalities occur in early pregnancy. Causes of Congenital Heart Disease (CHD) often can not be explained, although several factors are considered as a potential cause (Rahayoe, 2006). Congenital heart defects is heart defects or malformations that appear at birth, in addition to congenital heart disease is a disorder of the heart anatomy brought from conception to birth. Most congenital heart defects include structural malformations in the heart and major blood vessels, both the left and that leads to the heart (Nelson, 2000). This disorder is the most common congenital abnormalities in children, about 8-10 of 1,000 live births. This congenital heart defect does not always give symptoms shortly after birth, it is not unco...

Nursing Care Assessment Based on the information Nelson (2000), the data could focus on assessment of nursing care, among others: 1. Focus data : Increased body temperature usually occur in the afternoon. A history of respiratory tract infection. Decreased blood pressure, increased pulse rate, respiration increases. Non-productive cough. Epistaxis. Abdominal pain. Arthralgia. Loss of appetite. Losing weight. 2. Specific manifestations: Carditis: tachycardia cardiomegaly voice murmurs changes in heart sound ECG changes (PR lengthwise) precordial pain pericardial friction rub Polyarthritis joint swelling, heat, redness, tenderness. spread on the knee joint, elbow, shoulder, arm. Subcutaneous nodules: swelling of the skin, soft palpable. coming shortly, in general readily absorbed. found on the extensor surfaces of the joints Chorea: irregular movements of the extremities, involuntary. involuntary facial expressions speech disorders emotional lability muscle weakness muscle tension when a...

Dehydration Definition Dehydration is a condition in which a person who is not fasting experiencing or at risk of dehydration vascular, interstitial or intra-vascular (Sell Lynda Carpenito, 2000: 139). Classification Classification of dehydration by Donna D. Ignatavicus there are 3 types: a. Isotonic dehydration Isotonic dehydration is lost water followed by the electrolyte so that the density remained normal, then this type of dehydration is usually not result in ECF fluid move to the ICF. b. Hypotonic dehydration Hypotonic dehydration is the loss of solvent from the ECF exceeds fluid loss, resulting in blood vessels become more concentrated. ECF osmotic pressure decreases, resulting in fluid moves from the ECF to ICF. Vascular volume also decreased, as well as cell swelling occurs. c. Hypertonic dehydration Hypertonic dehydration is ECF fluid loss exceeds the solvent is non-osmotic dehydration ECF decreased, resulting in fluid moves from ICF to ECF. Etiology Various causes dehydratio...

Nursing Care Plan for Pediatric Febrile Seizures Definition of Febrile Seizures Febrile seizures are seizures that occur on the rise in body temperature (rectal temperature of more than 380C) which is caused by an extra-cranial process. Febrile seizures occur in 2-4% of children aged 6 months - 5 years. Children who have had seizures without fever, then re febrile seizures are not included in the febrile seizures. Febrile seizures in infants younger than 1 month are not included in the febrile seizures. When children aged less than 6 months or more than 5 years experience seizures preceded by fever, think of other possibilities, such as central nervous system infections, or epilepsy that happen to occur along a fever. Etiology Until now, the etiology of febrile seizures is not known with certainty. Fever is often caused by: upper respiratory tract infection, otitis media, pneumonia, gastroenteritis, and urinary tract infection. Seizures are not always arise at high temperatures. Someti...

Nursing Care Plan for Schizophrenia, Nursing Diagnosis : Disturbed Sensory Perception Schizophrenia is a disease that affects the brain and cause thoughts, perceptions, emotions, movement, strange and disturbed behavior (Videbeck, 2008). Nursing Diagnosis : Disturbed Sensory Perception hearing / vision related to: freaking out withdraw strss heavy, threatening the weak ego. Defining characteristics: talking and laughing themselves behave like listening to something (tilt the head to one side as if someone was listening to something). stop talking in the midst of a sentence to listen to something. disorientation low concentrations rapidly changing minds chaos groove mind response is not appropriate. Expected outcomes: Patients can be admitted that the hallucinations occur during extreme anxiety increased. Patients can say signs of increased anxiety and use certain techniques to break the anxiety. Planning: General purpose : Patients are able to define and examine the reality, reducing ...

Maslow's hierarchy of needs can be the basis for the nurse to make a priority nursing diagnosis. Maslow's hierarchy of five levels are: Biological and Physiological needs. Safety needs. Love and belongingness needs. Esteem needs. Self-Actualization needs. Physiological needs is a top priority and must be met before the needs of the higher level. Example of Maslow's hierarchy of needs : 1. Biological and Physiological needs : Respiration (circulation, temperature),  Hydration (avoiding pain, break or mobilization),  Nutrition (elimination, skin care),  Sey. 2. Safety needs. Environment free from danger. Stable living conditions. Regulations and laws in society. Free from threats. Clothes. Protection of the. Free from infection. Free from fear. 3. Love and belongingness needs. Affection. Seyyuality. Affiliates in the group. Relationship friends, family, community. 4. Esteem needs. Get respect from colleagues. The development of a sense of competence. Feelings of self-respec...

Congenital heart disease is a heart defect or malformation that appears at birth, in addition, congenital heart disease is a disorder of the heart anatomy brought from conception until birth. The cause of congenital heart disease can not be known with certainty, but there are several factors that allegedly have an influence on CHD. These factors are: 1. Prenatal factors: Mothers suffering from infectious diseases: rubella. Mother's alcoholism. Maternal age over 40 years. Mothers suffering from diabetes mellitus who require insulin. Mothers taking sedative drugs or herbs. 2. Genetic factors Children born before suffering from CHD. Father / mother suffering from CHD. Chromosomal abnormalities eg Down syndrome. Born with other congenital abnormalities. Congenital heart disease can be divided into 2 major categories, namely: Group 1. acyanotic congenital heart disease, include: Atrial septal defect (ASD) Ventricular septal defect (VSD) Patent ductus arteriosus (PDA) Pulmonary stenosis ...

Nursing Care Plan for Down's Syndrome Assessment 1. During the neonatal period, which needs to be studied: The state of the body temperature, especially the neonatal period. Nutritional needs / food. The state of hearing and sight. Assessment of cognitive abilities and mental development of children. Children's ability to communicate and socialize. Motor skills. The ability of the family in caring for down syndrome premises, especially on the progress of the child's mental development. 2. Assessment of motor skills. 3. Assessment of cognitive abilities and mental development. 4. Assessment of the child's ability to communicate. 5. A hearing test, vision and bone abnormalities. 6. How family adjustment to diagnosis and progress of mental development. Nursing Diagnosis for Down's Syndrome 1. Imbalanced nutrition less than body requirements related to difficulty feeding due to tongue far and high palate. 2. Risk for injury related to reduced hearing ability. 3. Ineffec...

Nursing Care Plan for Bronchopneumonia Definition Bronchopneumonia is an inflammation of the lungs that affects one or more lobes of the lungs characterized by patches of infiltrates (Whalley and Wong, 1996). Bronchopneumonia is the frequency of pulmonary complications, long productive cough, signs and symptoms usually increased temperature, increased pulse rate, increased respiration (Suzanne G. Bare, 1993). Bronchopneumonia also called lobularis pneumonia, is inflammation of the lungs caused by bacteria, viruses, mold and foreign objects (Sylvia Anderson, 1994). Etiology Bacteria : Diplococcus Pneumoniae, Pneumococcus, Streptococcus Haemolyticus Aureus, Haemophilus Influenzae, Bacillus Friedlander, Mycobacterium Tuberculosis. Virus : Respiratory syncytial virus, influenza virus, citomegalic virus. Fungi : Histoplasma capsulatum, Cryptococcus Nepromas, Blastomyces Dermatitidis, Coccidioides Immitis, Aspergillus Sp, Candida Albicans, Mycoplasma Pneumonia. Foreign body aspiration: Facto...

Definition of Personal Hygiene Personal hygiene is derived from the Greek language which means individual personal hygiene and healthy means. Personal hygiene is an action to maintain the cleanliness and health of a person's physical well-being. Personal hygiene is an individual effort in maintaining personal hygiene which includes cleanliness of hair, teeth and mouth, eyes, ears, nails, skin, and dressed in improving hygiene in optimal health (Effendi, 1997). Personal Hygiene is an act of maintaining the cleanliness and health of a person's physical and psychological well-being. The size of a person's cleanliness or appearance in fulfilling the needs of Personal Hygiene Personal differences in pain due to an interruption fulfillment. Purposes of Personal Hygiene Improve the health of a person. Illness and disability can affect immabolisasi. Maintaining the cleanliness of a person. Fixing personl hygiene is lacking. Prevent disease. Improving one's self-confidence. Crea...

Nursing Care Plan for Encephalitis Definition Encephalitis is an infection of the CNS caused by a virus or other microorganism that non-purulent. Encephalitis is an infection of the brain tissue by a variety of microorganisms. Encefalopati terminology that was used for the same symptoms, no signs of infection are now no longer in use. (Abdoerrachman, et al, 1985). Etiology A wide variety of organisms can cause encephalitis, such as bacteria, protozoa, worms, fungi, spirokaeta, and viruses. The most common cause is a virus. Infection can occur due to virus attacks the brain directly or acute inflammatory reaction due to systemic infection or previous vaccination. Encephalitis can also be caused by the direct invasion of the cerebrospinal fluid during a lumbar puncture. Various types of viruses can cause encephalitis, despite similar clinical symptoms. According to the type of virus and its epidemiology, known to a wide variety of viral encephalitis. Signs and Symptoms The clinical sympt...

Tuberculous spondylitis is a chronic granulomatous inflammation, destructive by mycobacterium tuberculosis. Tuberculous spondylitis is always a secondary infection from a focus elsewhere in the body. Percivall (1973) was the first author of this disease and states that there is a relationship between this disease with spinal deformity that occurs, so the disease is referred to as Pott's Disease. (Rasjad, 1998). Clinically, tuberculous spondylitis symptoms similar to symptoms of tuberculosis in general, the weakness / lethargy, decreased appetite, weight loss, slightly increased temperature (sub-febrile), especially at night as well as back pain. In children, often accompanied by crying at night. (Rasjad. 1998). At the beginning of radicular pain that can be found around the chest or abdomen, followed by paraparesis which was advancing more slowly, spasticity, clonus, hyperreflexia and bilateral Babinski's reflex. At this early stage of vertebral deformity has not been found, so...

Nursing Care Plan for Abdominal Tumor DEFINITIONS Abdominal tumor is a solid mass with different thickness, which may wrap around large blood vessels and ureter. In the pathology of this disorder is easy to peel and can extend to retroperitonium, ureteral obstruction may occur or the inferior vena cava. Mass of fibrotic tissue that surround and define the structure in the wrapper but not invaded. CAUSES The immediate cause of the tumor is actually not known, but there are some results of the study showed that: Excess nutrients, especially fat. The end result of metabolic and bacterial. Constipation. Infections, trauma, hypersensitivity to the drug. SIGNS AND SYMPTOMS Pain Anorexia, nausea, lethargy Weight loss Bleeding Enlargement of the existing organ tumors DIAGNOSTIC TEST Digital rectal test X - ray Sigmoidoscope Fiber optic scope plexible Ultra sonography Nursing Diagnosis and Interventions for Abdominal Tumor 1. Chronic Pain related to an emphasis on retroperitoneal organs, Chara...

Nursing Care Plan for AMI with ST elevation (STEMI) Definition Acute myocardial infarction is the destruction of tissue due to inadequate blood supply so that coronary blood flow is reduced. (Brunner & Suddath, 2002) Acute myocardial infarction is the death of myocardial tissue caused by myocardial coronary blood damage, due to the inadequate blood flow. (Carpenito, 2000) Acute myocardial infarction is ischemia or necrosis of the heart muscle caused by decreased blood flow through one or more coronary arteries. (Doengos, 2000) Etiology According to Noer, 1999; 103 caused by a. Causal factors: 1. Oxygen supply to the heart is reduced due to: a. Vascular factors: Atherosclerosis, spasm, arteritis. b. Circulation Factor: hypotension, aortic stenosis, insufficiency. c. Blood factors: anemia, hypoxemia, polycythemia. 2 Cardiac output increased For example: Activity, emotional, eating too much, anemia, hyperthyroidism. 3. Increased myocardial oxygen demand at: Myocardial damage, myocardi...

Nursing Diagnosis : Acute Pain r / t Increase in intraocular pressure (IOP) Definition Glaucoma is a group of eye disorders characterized by increased intraocular pressure. (Long Barbara, 1996) Glaucoma often occurs in both eyes, but extra fluid pressure first begins to build up in one eye. If you don't seek treatment for glaucoma and can't control it, your peripheral vision will decrease by time and subsequent eye damage may easily lead to blindness. Etiology There are different types of glaucoma. Most occur when pressure in the eye (intraocular) increases, damaging the optic nerve but sometimes optic nerve damage can occur even when intraocular pressure is normal. Other types of glaucoma are rare and are caused by abnormal eye development, drugs, eye infections or inflammatory conditions, interruption of blood supply to the eye, systemic diseases and trauma. Symptoms: Headaches. Sensitivity to light. Blurred vision. Decreased peripheral vision- gradual loss. Nausea and vomit...

Urinary Incontinence is urine output unnoticed in sufficient quantity and frequency, resulting in health problems and or social. Variation of urinary incontinence include out just a few drops of urine, to a really great deal, and sometimes also accompanied by incontinence Alvi (with expenditure feces). The etiology or cause of urinary incontinence is due to weakness of the pelvic floor muscles. This is related to the anatomy and function of the urinary organs. The weakness of the pelvic floor muscles can be due to several causes including pregnancy is repetitive, error in straining. This can lead to such a person can not hold urine (beser). Urine incontinence can also occur due to excessive urine production due to various reasons. For example, metabolic disorders, such as diabetes mellitus, which should continue to be monitored. Another cause is excessive fluid intake can be alleviated by reducing fluid intake as caffeine is a diuretic. Once we are aware of the meaning and causes of ur...